Objectives: To evaluated insurance-related variations in care for HIV-related Pneumocystis carinii pneumonia (PCP), and determine if variations are related to patient- or hospital-level factors.

Methods: This is a retrospective medical records review of 1395 patients from 59 hospitals in 6 cities. Patient and hospital characteristics were examined for impact on diagnostic and therapeutic resource utilization, as well as survival. We used chi-square and Wilcoxon rank sum statistics for univariate analysis and weighted linear regression for multivariate analysis. Generalized linear random effects modeling was used for the relationship between insurance and diagnostic bronchoscopy.

Results: Medicaid (n=735) and privately-insured patients (n=660) received care at different hospitals (p<0.0001). Timely anti-PCP or adjunctive corticosteroids therapy was unrelated to insurance status and hospital-specific rates did not vary by hospital case-mix of Medicaid vs. privately-insured patients. Mortality was also similar (11.6% vs. 11.9%, p=0.88), and after adjustment the odds of death remained similar (AOR=1.01, p=0.96). Fewer bronchoscopies were performed on Medicaid- than privately-insured (27.4% vs. 42.4%; p<0.0001). Multivariate random effects regression models found the patient-level effect was significant (AOR=0.72, p=0.02), but the hospital-level effect was not (AOR=0.93, p=0.13).

Conclusions: Insurance continues to be strongly associated with the intensity of diagnostic evaluation for HIV-related PCP, yet mortality was not worse with empiric treatment. This effect is primarily related to patientsí personal insurance status. There is a weaker hospital-level effect related to hospitalsí case-mix ratios.